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Abstract

Background and Purpose: Regular physical activity (PA) plays an important role in improving and maintaining one's health, especially as one ages. Although many older Americans are aware of the benefits of regular PA, the majority do not participate in regular PA that meets recommended guidelines. The purpose of this study was to gain insight into the motivators, barriers, and beliefs regarding PA of independent-living older adults with easy access to fitness facilities.

Methods: In this qualitative design, focus group interviews were used to explore the individual perceptions of physically active and inactive older adults regarding PA and exercise. Thirty-one older adults, over age 60 participated in focus group discussions regarding PA beliefs and behaviors. Groups were homogenous based on current PA behaviors. Demographic information was collected. Discussions were audiotaped and transcribed verbatim and deidentified. Two researchers independently coded for emergent themes. Interrater reliability was established (κ = 0.89). Peer review was used to further ensure trustworthiness and credibility.

Results: No significant differences were noted in age, body mass index, or educational levels between the physically active and inactive groups. Differences in perceptions were noted between the groups regarding the construct of PA, barriers to participation in regular PA, and the components of an ideal PA program. Physically inactive persons had much lower fitness expectations of a physically active older adult, more perceived barriers to regular PA, and required individual tailoring of a PA program if they were going to participate. In addition, inactive persons were intimidated by the fitness facilities and concerned about slowing others down in a group exercise setting. Both groups shared similar motivators to participate in PA, such as maintaining health and socialization; however, inactive persons also described PA as needing to be purposeful and fun.

Discussion and Conclusion: Physically inactive persons perceived themselves to be physically active, as their perception of PA was grounded in a social context. Although both groups shared some barriers to regular PA participation, physically active individuals developed strategies to overcome them. Issues relating to self-efficacy and stages of change need to be explored to address the individual perceptions and needs of inactive older adults if initiation or long-term adherence to a PA program is to be achieved.

INTRODUCTION

Regular physical activity (PA) plays an important role in improving and maintaining one's health and well-being, especially as one ages.1–4 Benefits of PA include lowering the risk of developing coronary heart disease, stroke, type 2 diabetes, hypertension, and some cancers.1,55–8 In addition, exercise increases strength, bone density, flexibility, and endurance while decreasing fall risk in older adults.3,5

At present, the PA recommendations for adults consist of at least 30 minutes of moderate-intensity PA 5 days a week and muscle-strengthening exercises at least 2 days a week. These guidelines are identical to the guidelines for generally fit older adults with no limiting health conditions.9–11 Older adults should also incorporate activities into their exercise routines that increase balance.3

As early as 1995 the Centers for Disease Control and Prevention and the American College of Sports Medicine (ACSM) called on physicians and health care professionals to counsel their patients routinely to adopt and maintain a regular PA program. In addition, a recent public health campaign, Exercise is Medicine, was instituted by the ACSM and American Medical Association, which calls on physicians to assess and review each patient's PA program at every health care visit.12 Although many individuals are aware that regular exercise improves health,13–15 60% of American adults are not regularly active, and 25% are not active at all.10,16 Reeves and Rafferty17 found that only 24% of older Americans aged 65 to 74 years participate in regular PA that meets the recommended guidelines.

Barriers and motivators to participation in regular PA have been well studied in the adult population. Barriers to regular participation in PA frequently cited in the literature include lack of time,18–20 ill health21,22 or changing health status,23 fear of injury,22 environmental considerations such as convenience/access,22,24 safety and cost,25,26 lack of knowledge,27 and lack of self-discipline or motivation.28,29

Motivators of regular PA participation include health care provider advice,30 intergenerational and family influences,23,26 improvement in physical or motor competence,31 health benefits,26 and psychosocial reasons such as enjoying the group interaction and meeting with friends.26–31,32 Chronic health conditions were identified as both a barrier and a motivator to PA in the older adult population, as individuals may exercise to prevent further physical decline but may be limited in their ability to participate in PA by the same conditions.19–21,26

Predictors of regular participation in PA have also been well documented. Gender, education level, age, and race are well established as correlates of PA15–33,34 as well as self-efficacy,35–38 greater social support,19 knowledge of perceived benefits,14,32 and a positive attitude toward PA.39,40 Engaging in regular PA or an early history of PA has also been noted as a predictor of future PA behaviors23,41–43 as well as education and income level,44,45 support from a health care provider,46 and environment.19–22,47 Single marital status or having a partner who is inactive has been negatively correlated with PA levels.48 In addition, researchers have also identified depression as negatively correlated with PA levels.49,50

PROBLEM AND PURPOSE

Administrators from a suburban Continuing Care Retirement Community (CCRC) in Montgomery County, Maryland, contacted the researchers regarding underutilization of available PA programs and services (pool, gymnasiums, fitness classes, and walking paths) by their clients who were residing in independent-living facilities. The CCRC offers a variety of PA programs for the older adult and a fitness center at no cost (Table 1). The administration and researchers wanted to gain insight into why clients chose to use, or not use, the facilities and programming. Thus, the overall purpose of this study was to investigate the barriers, motivators, and beliefs regarding PA and exercise of independent-living older adults with ready access to PA programming and facilities.

METHODS

Participants

Participants were recruited from a suburban Montgomery County, Maryland CCRC via flyers posted in high-traffic areas, word of mouth, and snowballing; no compensation was offered for participation in this research. Individuals interested in participating in the study contacted the researcher by telephone. Forty-one persons initially expressed interest in the study, and all met the inclusion criteria. The criteria consisted of age 60 years and older and currently residing in independent living in the CCRC. The University's institutional review board approved the study. Informed consent was obtained before the focus group discussions.

Instruments and Procedure

Focus group interviews were chosen to acquire detailed information about the attitudes and beliefs of older adults regarding PA. The focus group discussions explored individual perceptions of the terms “physically active” and “physically inactive,” motivators and barriers to engaging in regular PA, advantages and disadvantages of PA, and ideal PA programs. Participants were able to express their views in a supportive environment through the use of homogenous groups and group interaction.51 This methodology has been effectively used in research on aging52 and PA.26,53–55

Focus group assignment was based on the individual's current PA level to help to ensure that all individuals would be comfortable discussing their experiences with PA and exercise. A researcher screened all potential participants by telephone to determine each individual's current activity level. Modifications to the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance Survey 2001 questionnaire56 were made to determine the levels of PA in this population. Individuals were asked what type of PA or exercise, including leisure-time activities, they participated in on a regular, weekly basis. Prompts were provided when necessary. Persons were classified as “physically active” if they participated in moderate exercise at least 3 days per week for more than 30 minutes, in vigorous activity at least 3 days per week for more than 20 minutes a day, or in strength-training exercise at least 3 days per week for more than 20 minutes a day. Individuals were classified as “physically inactive” if they participated in less than 10 minutes total per week of moderate or vigorous lifestyle activities, such as housework, gardening, and walking, or if they participated in more than 10 minutes of moderate or vigorous activities, but less than the recommendation for a physically active individual. The focus group size was capped at 10 participants to ensure ample time for each individual to express his or her view and to allow the moderator to guide the discussion.

The focus group questions and moderator's script were developed by a panel of 3 experts in the fields of physical therapy and exercise science. Two pilot focus group discussions were conducted by one of the researchers acting as a facilitator: 1 focus group discussion with physically active individuals and 1 with physically inactive individuals. Feedback from the participants resulted in changes to the original scripts, which were agreed upon by all panel members. Focus group questions ranged from broad topics, such as “When you think of physically active older adults, what images come to mind?,” to more specific topics, “What gets in the way of exercising for you? That is, what are your major barriers?” The facilitator probed for confirming, disconfirming, and missing information.57

A total of 6 focus group discussions were then conducted by a researcher acting as a facilitator. Each focus group discussion conducted included 2, 45-minute sessions with a 10-minute break in between, for a total of 90 minutes per group. This time frame was adequate to achieve saturation. The total number of minutes per focus group discussion ranged from 82 to 87, with an average of 85.2 minutes. Three focus group sessions were conducted for individuals who were identified as “active” (n = 6, n = 7, and n = 9) and 3 were conducted for individuals identified as “inactive” (n = 3, n = 2, and n = 4). The facilitator had formal training and experience in conducting focus groups with older-adult populations. An audio recorder was used in each session to accurately record the discussion, and a note taker was present during each session to record individual remarks and body language of the participants.

DATA ANALYSIS

Approach

Participant characteristics were summarized by using descriptive statistics based on the data gathered from the demographic questionnaire, which included self-reported age, weight, height, and educational level. Body mass index was calculated by using the standard formula of weight in kilograms divided by height in meters squared. Significance of the demographic variables was assessed by using independent t tests.

In this qualitative study, a phenomenological approach was taken to analyze the data on the basis of the steps described by Creswell58 and Riemen.59 The focus group discussions were audiotaped and transcribed verbatim and deidentified to ensure participants' confidentiality. One active and 1 inactive transcript were independently coded by 2 researchers by using the open-coding method described by Patton.60 Each coding schema was operationally defined. Axial coding then allowed for easier identification of key words and phrases associated with the emerging themes. Coding schema interrater reliability was determined by using the κ statistic. Once substantial agreement between the 2 researchers was achieved (≥0.8),61 the remainder of the data were coded. A number of steps, including the use of multiple researchers, completion of interrater reliability, the use of verbatim quotes to support emerging themes, and the use of a peer reviewer to confirm the accuracy of the results, were taken to ensure trustworthiness and credibility of the analysis.

RESULTS

Forty-one persons initially expressed interest in the study. Thirty-four individuals agreed to participate; however, 3 of the 34 participants did not show for their scheduled focus group discussion. All 3 were classified as physically inactive. Of the remaining 31 participants, 30 completed a demographic questionnaire. The 1 individual who participated in the focus group discussion but chose not to complete the questionnaire gave no reason. Of these individuals, 21 (70%) were identified as physically active and 9 (30%) were identified as physically inactive. Women represented 47% of the physically active group and 100% of the physically inactive group. Participants' ages ranged from 60 to 94 years, with a mean of 80 years. The mean age of the physically active participants was 78.8 years (SD = 7.69) and the physically inactive participants was 82.8 years (SD = 8.37). The mean length of stay for all individuals residing at the retirement community was 5.56 years, with an average stay of 3.7 years for the more-active group and 10.4 years for the less-active group (Table 2). Additional descriptive statistics are also found in Table 2.

Identified Themes

Physically active images

When physically active participants were asked, “What images come to mind when you think of a physically active older adult?” 2 main themes surfaced: individuals who were exercising and individuals who were busy. Exercise varied from walking (for transportation or health benefits), to exercising in the fitness center (stationary bike, weights, treadmill, and group classes), and to recreational activities, such as biking, hiking, and rock climbing. The concept of “being busy” was described by acts of volunteerism, participation in social activities, and “going places.”

Those who were physically inactive were less likely to describe a physically active person as using the gym or participating in exercise classes as compared with the physically active group. The most frequently cited form of exercise in this group was walking. Volunteerism was also mentioned as a form of being physically active. In fact 1 person commented, “I do not think of a [physically active] person who is doing physical exercise, but [someone] who does a lot of volunteer work outside of his or her apartment.”

Physically inactive images

When asked “What images come to mind when you think of physically inactive older adults?” 3 themes emerged that were common to both groups. All participants spoke of an emotional component, a social component, and a mobility component. Both groups reported that physically inactive persons were less likely to be or look happy and that inactive persons had lost interest in life. Those in the physically active group responded in greater detail regarding the emotional component stating that physically inactive persons are “probably more depressed...because of not having those endorphins circulating,” and “I think of someone who is not very happy and complains a lot and just sits around and doesn't do hardly any activities.”

Social isolation was also a common theme expressed by both groups when describing persons who were physically inactive. Some quotes that exemplify this theme include “they don't care to join in groups, even say the coffee hours in their buildings or the sing-alongs, they just stay home” and “they just don't get out of their apartment. They don't participate in anything...,” and “You just don't see them.”

All participants identified physically inactive persons as having mobility impairments. Physically active individuals commented that inactive individuals were “people on scooters or wheelchairs” or that physically inactive persons “don't have mobility.” Individuals who were less active also described mobility impairments but developed this concept further and described the resultant effects of the mobility impairment on individuals' participation and activities. They commented that physically inactive persons were probably in the affiliated skilled nursing home or “they have daycare help because they're so bad off that they can't do anything for themselves,” and “if they don't want to be in the health care center [skilled nursing home]...they have their own private caretakers.”

Motivators of physical activity

Several primary themes emerged from the physically active focus group discussions regarding motivators of PA. They included health concerns, socialization, and staff/programming. Secondary themes, including accessibility (eg, convenience, cost, and safety), facilities, socialization, fun, and encouragement from one's physician, were also identified as motivators in this group. Concerns about one's health were the most frequent responses. Some individuals initiated exercise in response to an already-identified health condition, such as Parkinson disease or osteoarthritis, or after a surgery; “the main reason I started at the fitness center was because I had a knee replacement..., but I have to keep my knee, you know healthy and exercise,” and “[I have] a little bit of fear having been told I have Parkinson's. I don't know where I'm going but I'm going to keep myself in as good shape as I can and live with whatever happens, and it's a sense of mortality that drives some of us.” Others were exercising to stay healthy or to combat the effects of aging. For example, “so they say doing aerobics is good for you and so therefore that's what I'm going to be doing,” and “I couldn't walk up a flight of stairs without feeling out of breath...and that was one of the things that stimulated me that I, I felt I was disintegrating and I had to do something about it.”

Physically active participants frequently identified the social aspect of exercising in a group as a motivator to exercise. Individuals were motivated by either exercising with a spouse or significant other, “I'm in the swimming program because my wife is in the swimming program,” or the ability to meet new people or maintain contacts with “exercise friends.” One participant put it simply “I would say that the draw [to exercise] is companionship really. You have a social fitness group that's a support group too,” and “I regularly go to the fitness room, and one of the things I really like about it is that it's sociable; you meet people you wouldn't meet otherwise.”

The exercise staff was frequently cited as motivator to exercise from 2 perspectives: personal encouragement and education and knowledge. One participant commented about a particular fitness instructor's ability to motivate individuals to exercise, “and I think anyone who has worked with Trainer X at the fitness center knows he is the motivating factor,” which led to enthusiastic agreement among the focus group participants. Knowledge and education of the equipment were also particularly important to this group, which is exemplified by comments such as “ this is where the assistance of the trainers are much more beneficial than I would have anticipated before I began to get old,” and “I'm glad I have the trainers here to show me what to do and how to set the machines, so they're right for me.”

Physically active participants also identified reasons why they continued to exercise on a regular basis. The most frequent response was to improve or maintain health. For example, “[with regular exercise] I've been able to get off the anti-inflammatory that I had been on for a long time...I feel so much better all the time,” and “I used to have a lot of trouble with my back and I found after exercising...I didn't have that” are quotes that typify this discussion.

The physically inactive group had slightly different responses when describing motivators of activity. Physical activity had to be purposeful, social, and fun. Walking was the primary form of PA noted, usually with a companion. Walking was described, in most situations, as having a goal (eg, going to the store or a meeting in another building). One participant responded, “I did that once [exercise] and I enjoyed it because I was doing it with other people. I don't like to do things by myself.” Another person added, “I don't think I ever did anything that there wasn't a purpose, like my physical therapy...I knew I had to do it [to get better],” and “I walk not as an exercise...it is an ecology thing; I try—if I don't need to take a car, I don't take the car.”

Barriers to physical activity

In response to the question “What gets in the way of exercising for you? That is, what are your major barriers?” the physically active group responded with 2 major themes: lack of time and potential for injury. Two quotes illustrating these themes are “I have so many other activities that I do too, that sometimes I just don't have enough hours in the day” and “I have to be careful with the weights, I have carpal tunnel, but I do some [exercises] but they're—they're minimal, so I don't—you know aggravate that.” Although the majority of respondents were retired, many had multiple regular volunteer responsibilities in addition to social and committee activities, with heavy time commitments. Although mentioned less frequently, finding the discipline to maintain a program was also noted by a few respondents.

The inactive group responded with 6 major barriers to participating in regular PA. These themes included lack of time (including difficulties prioritizing), potential for injury, self-discipline, motivation, boredom, and intimidation. Some quotes illustrating these barriers are “there isn't time to do everything you're supposed to be doing” and “well you have the time, it's just the way you make use of the time.” The participants were also very candid about their lack of self-discipline and motivation when trying to adhere to an exercise program. “I'm not very disciplined,” and “[I] just couldn't get myself motivated” were the comments that elicited agreement among group members. Boredom was also a theme that was frequently cited, “I kept it [exercise] up for about a year and I found it incredibly boring.” Some respondents noted that there were “much more interesting” things to do rather than exercising, which developed into a conversation about various trips and clubs at the retirement community.

The gym atmosphere and joining an already-established exercise group and/or program were intimidating to this group causing an additional barrier. Participants were concerned that they would “slow the class down” or cause the group “to wait for me.” Quotes that illustrate these findings include “They have a walking group, and I haven't joined because I figure I won't go as fast as they go, and so I wouldn't be able to keep up” and “They do have a lot of programs here and if you got in on the beginning of them then I think you're okay; but if you don't then they've moved on...”

The ideal physical activity program

When participants were asked to describe the ideal exercise program that would encourage them to be physically active, participants who were physically active responded most frequently that it should be easy to access (eg, close proximity to their home, in a safe environment, and free of cost) and have knowledgeable staff. One participant stated, “I don't mean to sound too coarse or anything but everybody wants it to be free” and another person stated “the thing I like about the—the classes...they are free and you don't have to go every single time.” These individuals were equally concerned about physical access to the fitness center for all residents. “There are people who had strokes or people who have serious mobility problems...they don't have the ability to easily get to the fitness center and I know there are people who would like to have some machines, on a minimal level, in their own building.”

A knowledgeable staff that educates residents about equipment use was equally important to both groups in an ideal fitness program. A sample quote from a physically active participant demonstrates this finding: “But it is essential that I have the help of the staff in guiding me; you know if that machine gives you a problem, why don't you try this?” However, less-active participants were more concerned about the staff meeting the individual needs of each person or a group of persons. One participant commented, “if there was...an introductory walking class, would you be more apt to join something ...than an already established walking club? Ah...probably,” and “I think if they had that attitude [in reference to one-on-one training] in the exercises here, that that would help for people to go to the exercises more.” In addition, those who were less active were concerned about slowing down others in a group setting, suggesting that the staff “institute a new type program for people such as us [less physically active] rather than trying to make these other people [physically active] do like we have to do.” These comments also reflect the theme mentioned earlier, that of intimidation.

Convenience and easy access were also noted by the less physically active group as important in an ideal exercise program. “People would participate more if it's inside their building for the most part.” The less physically active participants also suggested that ideal programming would have variety and be fun and social.

Advantages and disadvantages of physical activity

When participants were asked, “What are the benefits of exercise for older adults?” both groups identified 2 main themes: health benefits and emotional benefits. A comment from a physically active participant typifies the emotional benefits: “the fact that you are able to do more things, it allows you to help other people, which is really key to being happy.” An overarching comment from an inactive participant addresses both themes: “your own common sense tells you that you need to exercise... as far as I'm concerned I think exercise stimulates your mental capacity too, not only your body.”

Respondents in both groups voiced concern that the disadvantage of exercise for older adults was the potential for injury, which was addressed earlier as a potential barrier in both groups. A comment from an active participant illustrating this theme is “but almost everybody around this table is somewhat fearful of falling and hurting themselves.” However, the physically active individuals appeared to understand that exercise might need to be tailored to individual needs to be beneficial. This is illustrated in the comment, “it depends on the individual so much and their individual health and needs you-you really have to check it out because what may really benefit one person may harm another.”

The less-active respondents were also concerned about falling during PA; however, they were equally concerned about potential negative physiological consequences associated with exercise, such as early osteoarthritis. A typical comment from this group was “I've heard that really after a certain age, probably running isn't particularly good for your joints...walking is probably better and will do less damage to your joints.” And another inactive participants postulated about the cause of joint replacements: “I raised the question if jogging isn't bad, why do so many people have knee replacements now and hip replacements; because it's-it's putting pressure on your joints.”

DISCUSSION

The purpose of this study was to investigate the barriers, motivators, and beliefs regarding PA and exercise of independent-living older adults with ready access to PA programming and facilities. Motivators and barriers to PA have been well documented in the older-adult population. One barrier to PA frequently cited in the literature is access (physical/cost/safety) to appropriate fitness facilities. Although individuals studied in this population had easy access to a state-of-the-art fitness center with a knowledgeable staff, the administration estimated that only 10% to 15% of all resident in independent living regularly utilized the facilities. Demographic information of the 2 groups was similar; therefore, insight into the perceptions of the 2 groups was gained through focus group discussions. Differences were noted in group perceptions of physically active and inactive older adult images, motivators and barriers to regular PA, and what would constitute an ideal PA program.

Although the residents' reasons for choosing this particular CCRC were not addressed in the focus group discussion, the length of time the residents have been living in the community may offer some insight. Five of the 9 inactive participants chose to live at the CCRC before the building of the wellness and fitness center. Thus, it is reasonable to assume that the fitness center was not a draw for these persons when making their decision to join the community. Although some PA programming was available, it was limited in nature and might partially explain the participants' lack of PA interest and subsequent use of the facilities. In contrast, only 3 of the 21 active participants arrived at the CCRC before wellness and fitness center construction; therefore, these individuals might have considered the PA facilities and programming in their overall choice of living facilities.

Physically Active and Inactive Images

Those who were currently physically active described a physically active older adult as involved in more vigorous forms of PA, such as biking, hiking, jogging, and gym use, while those who were less physically active described a physically active person as someone busy volunteering, whose primary form of exercise was walking. In essence, all participants, regardless of their own PA behaviors, were describing themselves as being physically active.

The differences in group perceptions were even more apparent when groups described someone who was physically inactive. Physically active individuals described physically inactive persons as individuals with mobility problems, who may be unhappy. Although physically inactive persons described physically inactive older adults, who may be depressed, as having mobility problems, they also described the functional consequences of restricted mobility. They described a physically inactive older adult person with a much lower level of function; for instance, the individual was either bed bound, required physical assistance for activities of daily living, or was living in a skilled nursing facility. What was particularly striking was that the persons in physically inactive group appeared unaware that they would be considered physically inactive on the basis of the guidelines described earlier. Thus, the inactive participants appeared to have lower expectations for PA when they considered PA as a construct. Other researchers have noted that older adults' perceptions when describing PA may change as they age. They may describe themselves as “active enough” through their leisure-time or domestic activities,33 such walking, gardening, or housekeeping,62,63 or as embedded in their social lives.64

Motivators and Barriers

Although motivators of PA were similar in both groups, the inactive group cited many more barriers to regular participation in PA as compared with the active group (6 vs 2). Physical activity for the inactive group had to be purposeful and meet the individual needs of the person, while the active group appeared to enjoy exercise regardless of its purpose. Both groups cited lack of time as a major barrier; however, the active group prioritized their activities such that exercise came at the top of their list. Use of strategies and finding solutions by more physically active individuals was also noted by O'Brien Cousins65 in her study of older adults and PA behaviors. The persons in the inactive group had different priorities for time use; they found PA to be boring and chose instead to engage in other social activities. Inactive participants were very honest about their lack of motivation and self-discipline when trying to initiate or maintain a PA program. They also appeared to be intimidated by the gym facilities and the speed at which an exercise class progressed, as demonstrated by their concerns about “slowing others down.” These findings illustrate the need to tailor physical activities and exercise to meet individual interests and fitness levels when designing a PA program, which has also been suggested by other researchers in the field.66,67

The inactive group concerns of “slowing others down” highlight the need to address the construct of self-efficacy and its relationship to exercise behavior. Bandura68 identified self-efficacy when formulating the social cognitive theory. It is defined as a person's belief in his or her ability to be successful in performing a specific behavior. Simply stated, if the individual has confidence in his or her ability to successfully participate in a PA and exercise program and has positive outcomes associated with it, he or she is more likely to initiate and/or maintain the program. Research has demonstrated that self-efficacy is consistently and positively related to the exercise behaviors of older adults.35–69,70 Some factors identified as sources of exercise self-efficacy in older adults include degree of social support from the exercise group, frequency of exercise,35 and group cohesiveness.71 There also appears to be some gender differences as there are higher levels of exercise efficacy noted among older women receiving social support.72,73 Although exercise self-efficacy was not formally addressed in the focus group discussion, comments from those who were inactive clearly demonstrated that they were anxious about using equipment and facilities, concerned about slowing others down in a group, and more fearful of injury. It may be that these concerns are associated with their lower PA patterns and behaviors.

Fear of injury and/or fear of falling are commonly cited in the literature as barriers to PA for older adults.74–76 Efforts to address these fears should include a program tailored to meet individual needs, in addition to an educational component highlighting safety, joint protection, and the importance of a warm-up and cooldown, as well as gradual exercise progression. Incorporating an age-matched behavioral coach has also been successful in reducing fear,77 as well as the additional benefit of providing exercise in a social context.

Inactive individuals also described past efforts to participate in a regular PA regime. The Transtheoretical Model of behavior change, originally developed in the psychotherapy process, was adapted by Marcus and colleagues78 to demonstrate the stages of change, indicating readiness to participate in exercise. This model can also apply to our focus group participants. The physically inactive participants appear to be in an earlier stage of change, either precontemplation or contemplation, as compared with the physically active participants, who are in an action or maintenance stage. Although one would like to postulate that additional education on the health benefits of exercise would motivate sedentary individuals to change their activity patterns, Cress and colleagues66 noted that knowledge of PA benefits alone is insufficient to motivate sedentary individuals to initiate or maintain an exercise program. This was apparent in our discussions in the inactive focus group, as all participants were familiar with the physiologic and psychosocial benefits of exercise. So how does one move an inactive individual from an earlier stage to an action stage? Greaney et al79 found that tailoring intervention strategies to ones' stage of change, with the use of behavioral change strategies and encouragement, was moderately effective in shifting individuals who were in stages of change other than maintenance. Moreover, Litt et al72 also noted that the principal predictors of initiation of exercise were readiness to exercise and social support for exercise. Therefore, accounting for one's stage of change when designing a new PA program for less-active adults may lead to better, long-term exercise adherence.

Continuing Care Retirement Community Recommendations

Once the focus group discussions were completed and themes analyzed, a presentation was made to the administration and fitness center support staff, with a variety of recommendations to improve regular PA participation. Suggestions included the following: offer individual fitness assessment by staff so that PA program choices could be tailored to individual needs with referral to a physical therapist for persons with complex comorbid conditions; track peak fitness center time use and post the information for residents so that they could determine when the fitness center and staff may be less busy and, therefore, more available to address individual resident needs; institute an exercise pal or buddy program in each building so that newly active residents could benefit from a peer coach; post a walking list in each building of persons who would be interested in participating in a regular walking program; increase the number of exercise programs geared toward those with mobility impairments such as the seated exercise class; include regular introductory exercise classes for new residents or long-time residents with new PA interests, as they may be more willing to attend an exercise class that is introductory in nature; offer some exercise sessions in 1/2-hour increments, as some residents have limited endurance; and analyze the walking trails on campus to determine safety and accessibility throughout, in addition to adding more benches so that those with limited endurance can sit down and rest. A comprehensive dialogue ensued. Feedback was well received and some of the suggestions have already been instituted. Ongoing communication between the CCRC and the researchers continues, with potential for follow-up under consideration.

Implications for Practice

If one considers the perceptions of inactive persons in this study regarding the construct of PA, motivators and barriers to regular PA, and the ideal PA program, an effective strategy to consider when instituting a PA program for older physically inactive adults may be to (1) include a PA education program that addresses all forms of moderate-intensity exercise and principles of behavior change supervised by knowledgeable staff, (2) tailor the exercise program to meet individual needs; this may include incorporating leisure-time activities that the person is already familiar with, and (3) consider incorporating the PA program within an already existing social context (eg, an already-existing group, such as a church or book group) to provide for social exercise support. In addition, since higher levels of exercise self-efficacy have been associated with higher levels of exercise adherence, continued staff and social support may be key to the long-term maintenance of a PA program. As Litt and colleagues72 noted, the principal predictors of initiation of exercise were readiness to exercise and social support for exercise, followed by exercise self-efficacy to maintain an exercise behavior. Thus, continued staff and social support would help to ensure higher levels of self-efficacy and better long-term outcomes.

Limitations and Future Studies

This study examined the barriers, motivators, and beliefs regarding PA and exercise of independent-living older adults with ready access to PA programming and facilities. Recruitment of less physically active persons was difficult, resulting in more than twice as many physically active participants. Crombie and colleagues80 have shown that higher activity levels have been associated with higher recruitment, thus leading to a selection bias.81 Thus, transferability of the findings is limited due to the small sample size and limited number of inactive participants.

Participants composed a highly educated and nondiverse sample from 1 suburban CCRC, which might reflect the attitudes and beliefs of one's geographic and socioeconomic perspective. Although background demographic information did not ask about income level, the cost of entrance to the CCRC limited the recruitment of individuals with a more modest income, thus also limiting the transferability of the study.

Credibility could have been enhanced by including a participant check of the focus group transcripts. In addition, one of the researchers acted as the facilitator of the focus group discussions, and thus, the potential for researcher bias affecting the direction of the discussions exists.

Physically active and physically inactive were operationally defined by the authors on the basis of modifications to the existing ACSM and American Heart Association recommendations for PA in the adult population.4 Definition modification may limit the transferability of the findings.

Future studies should include a larger sample size and attempt to target individuals from different socioeconomic backgrounds as their perceptions of PA, barriers, and motivators may differ. Additional methods of recruitment should be utilized to ensure adequate representation of individuals who are less physically active. Triangulating the data with additional outcome measures such as the 36-Item Short Form Health Survey would lend additional credibility to the study design and add to the understanding of self-efficacy, as it relates to PA and the concept of activity and participation.

CONCLUSIONS

Barriers and motivators to regular PA along with the construct of PA were explored by using focus group discussions in physically active and physically inactive older adults with ready access to fitness facilities and staff support. Although both groups easily identified the benefits of regular PA, differences were noted in group perceptions of what a physically active and inactive older adult would look like, barriers to participation in regular exercise, and what would constitute an ideal PA program, if undertaken. Less physically active individuals had much lower fitness expectations of a physically active older adult, more perceived barriers to regular PA, and required tailoring of PA to meet individual needs. The members of this group also perceived themselves to be physically active, though they were not, as their definition of PA was based on a social context. Issues relating to self-efficacy and stages of change were explored to address these findings. Individual perceptions and needs of older adults should be taken into consideration when developing a PA program to increase the chances of long-term success.

3. US Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention; 1999. http://www.cdc.gov/nccdphp/sgr/contents.htm. Accessed December 1, 2010.

4. Haskell WL, Lee I, Pate R. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39:1423–1434.

6. Pate R, Blair S, Haskell WL, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports medicine. JAMA. 1995;273:402–407.

11. Nelson ME, Rejeski J, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116:1094–1105.

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